There are some significant differences in critical care rules as described in CPT and in the Medicare Claims Processing Manual.1
This makes it difficult for physicians and coders alike. Although I usually don’t suggest using Medicare rules for all payers, I do suggest it for critical care in adult medicine.
Use of emergency department codes and critical care codes on the same day
CMS specifically prohibits billing an ED visit and critical care on the same day, by the same physician. Keep in mind the rule about billing for services by physicians in groups: bill for physicians of the same specialty in the same group as if they were one physician.
That means, one ED doctor can’t bill for 99285 and a second ED doctor in the same group bill 99291. And, no physician can bill both an ED visit and critical care on the same calendar day.
From the manual:
“Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician to the same patient.”
CPT does not make this distinction. It simply says:
“Critical care and other E/M services may be provided to the same patient on the same date by the same individual.”
Neither CPT nor Medicare prohibit billing other E/M services on the day of critical care, if they were separate and distinct. That means, the services were provided before or after the critical care service, at a time when the patient was not critically ill.
For example, if a patient is seen in rounds in the morning, and becomes critically ill later in the day, both the subsequent hospital visit and critical care may be billed. Append modifier 25 to the subsequent hospital visit. Expect the payer to ask to see the notes before paying the claim.
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